The psychiatric-mental health nurse is performing the admission assessment of a client who is being admitted for depression and anxiety. The client reports a long history of excessive alcohol use and the recent loss of her job. When the nurse asks whether she has a religious preference or affiliation, the client states. "I used to believe in God, but I do not anymore. I do not understand how God can allow terrible things to keep happening to me.' Which nursing diagnoses will the nurse include in the client’s care plan?
Risk for lack of faith
Risk for spiritual distress
Risk for impaired religiosity
Risk for impaired spirituality
The Correct Answer is B
The client's statement about losing faith in God and not understanding how God could allow bad things to happen to her suggests that she is experiencing spiritual distress. This can be common among individuals experiencing depression and anxiety, as they may struggle to find meaning or purpose in their lives.
Option a, Risk for lack of faith, is not a recognized nursing diagnosis.
Option c, Risk for impaired religiosity, may be more appropriate for a client who has experienced a significant change in their religious practices or beliefs but does not necessarily indicate distress.
Option d, Risk for impaired spirituality, could be appropriate but may be too broad and not specific enough to the client's situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
These terms could be used to describe and document a client’s motor activity on a mental health assessment. Tics are involuntary movements or vocalizations that are sudden, rapid, and repetitive. Restlessness refers to an inability to sit still or remain calm due to physical or emotional discomfort. Echopraxia is the involuntary repetition or imitation of another person’s movements. Flat and guilty are not terms used to describe motor activity.
Correct Answer is A
Explanation
Disassociation is a defense mechanism that involves mentally separating oneself from a stressful or traumatic situation in order to maintain a sense of calm and focus. In this scenario, the nurse is able to block out the sirens and alarms, which may be causing stress and anxiety, and maintain a calm and focused demeanor while speaking with the client's family. This is an adaptive use of disassociation because it allows the nurse to provide effective care and support to the family despite the chaotic environment.
Denial is a defense mechanism that involves denying or minimizing the existence of a stressful or traumatic situation. Rationalization involves justifying or excusing one's behavior or actions. Altruism involves selflessly helping others as a way of dealing with one's own problems. In this scenario, none of these defense mechanisms are being used by the nurse.
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